Capella 4035 Assessment 2

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Root-Cause Analysis and Safety Improvement Plan

Understanding the Incident

Sentinel events represent serious breaches in healthcare delivery that compromise patient safety and are not typically linked to the underlying medical condition. These occurrences can lead to severe harm, emotional distress for families, and professional repercussions for clinical staff. To investigate such events, root-cause analysis (RCA) is utilized to explore both direct errors and systemic failures. Through this analysis, healthcare organizations can design interventions that address vulnerabilities and prevent recurrence.

In a recent scenario, a patient arrived at the Emergency Department (ED) in septic shock. A critical lapse happened during a nursing shift handoff, where the outgoing nurse failed to provide key clinical updates, and documentation was poorly executed. Consequently, the patient’s condition deteriorated, requiring prolonged hospitalization and additional treatment. This incident highlighted the emotional toll on staff and revealed communication failures and policy weaknesses within the organizational system.

Analyzing Contributing Factors

Root Causes and Contributing Elements

The RCA identified several underlying problems. Human factors such as fatigue, unclear communication, and inadequate training in structured handoffs played a central role. Heavy reliance on verbal exchanges without parallel written documentation elevated the risk of miscommunication. Contributing environmental factors included a poorly arranged ED, lack of digital handoff systems, and staffing shortages, which together hindered seamless care delivery.

Differences in language and culture further complicated communication in a workforce lacking standard training in structured communication practices. Additionally, the healthcare institution had not emphasized the significance of handoff protocols, and leadership failed to monitor compliance, revealing issues in staff training, leadership involvement, and system design.

Deviation from Standards

The SBAR (Situation, Background, Assessment, Recommendation) communication model was not properly followed. The outgoing nurse delivered an incomplete handoff, and the receiving nurse failed to clarify the missing information. Vital aspects of the patient’s condition and care plan were omitted from the report, leading to a clear violation of protocol.

Roles, Communication, and Environment

Personnel Involved

The key personnel involved in the incident included the two nurses during the shift change and the attending physician, who modified the care plan but failed to confirm its communication. The charge nurse did not enforce protocol compliance, and administrative oversight was absent during this period, further escalating the risk

Communication Breakdown

There were notable communication failures between nursing staff and the physician, particularly concerning the patient’s deteriorating condition. The absence of clear updates compromised the quality of care. Furthermore, the patient and their family were not adequately informed, reducing their ability to participate in care decisions and consent.

Environmental and Staffing Constraints

The ED’s fragmented layout and equipment failures created barriers to timely monitoring and effective communication. Staffing limitations stretched available personnel, leading to missed assessments. Though the staff was clinically capable, they lacked targeted training for high-acuity cases and complex pharmacologic regimens.

Organizational and Monitoring Shortfalls

Policy Implementation Issues

Although handoff and safety policies were available, they were inconsistently implemented due to their complexity and lack of accessibility. This led to non-standardized practices across shifts, reducing the efficacy of those guidelines.

Monitoring Failures

During critical phases, vital signs were not closely observed, and alarm fatigue led to missed urgent alerts. The sheer volume of non-critical alarms dulled staff responsiveness to truly urgent ones. These gaps in monitoring and alert systems pointed to failures in alarm management and system configuration.

Recommendations and Safety Enhancements

Lessons and Improvement

To prevent recurrence, significant systemic changes are essential. Standardizing SBAR use across all shift changes should be a priority. Communication-focused training and fostering a culture of transparency are also vital. Leveraging digital handoff tools and implementing real-time monitoring can enhance accuracy and coordination.

Patient Safety Measures

Safety can be bolstered by installing intelligent alert systems for high-risk patients, conducting simulation training regularly, and redesigning alarm protocols to reduce desensitization. A feedback-based, blame-free reporting culture should be encouraged to drive ongoing improvement.

Root Cause(s) and Contributing Factors

Factor Category	Identified Issue	Classification Code
Communication Breakdown	Failure to convey critical patient updates during handoff	HF-C (Human Factor – Communication)
Training Deficiencies	Inadequate training on handoff best practices	HF-T (Human Factor – Training)
Equipment Malfunction	Alarm systems did not alert staff to patient deterioration	E (Environment/Equipment)
Staff Fatigue	Extended shifts compromised focus and performance	HF-F/S (Human Factor – Fatigue/Scheduling)
Policy Non-Adherence	Inconsistent compliance with safety protocols	R (Rules/Policies/Procedures)
Communication Infrastructure	Absence of structured digital communication tools	B (Barriers)

Application of Evidence-Based Strategies

Intervention	Strategy	Supporting Evidence
Structured Communication	Implement SBAR for all clinical handoffs	Mulfiyanti & Satriana (2022)
Simulation-Based Training	Regular emergency simulations and refresher programs	Shaoru et al. (2023)
Alarm Optimization	Adjust alarm settings to minimize fatigue and maximize impact	Shaoru et al. (2023)
Routine Audits and Feedback	Monitor compliance and incorporate continuous feedback	Argyropoulos et al. (2024)

Safety Improvement Plan

Root Cause	Planned Action	Timeline
Communication Failures	Enforce SBAR for every shift transition	Initiate in 1–2 months
Training Gaps	Roll out structured onboarding and emergency simulations	Begin within 3 months
Alarm Desensitization	Calibrate alarms and provide alarm fatigue training	Implement over 3–6 months
Policy Non-Adherence	Simplify and centralize safety protocols	Complete in 3 months

Existing Organizational Resources

Resources Available	Resources Needed
Senior staff experienced in clinical education	Specialized SBAR and alarm management training programs
EHR system supporting internal communication	Advanced patient monitoring systems and real-time alerts
Active safety and quality improvement committees	Dedicated budget for staff development and technology upgrades

References

Argyropoulos, C. D., Obasi, I. C., Akinwande, D. V., & Ile, C. M. (2024). The impact of interventions on health, safety and environment in the process industry. Heliyon, 10(1), e23604–e23604. https://www.sciencedirect.com/science/article/pii/S2405844023108127

Mulfiyanti, D., & Satriana, A. (2022). The correlation between the use of the SBAR effective communication method and the handover implementation of nurses on patient safety. International Journal of Public Health Excellence (IJPHE), 2(1), 376–380. https://doi.org/10.55299/ijphe.v2i1.275